Beyond neural cubism: promoting a multidimensional view of brain disorders by enhancing the integration of neurology and psychiatry in education

Unveiling the Potential of Phytocannabinoids: Exploring Marijuana's Lesser-Known Constituents for Neurological Disorders

Cannabis sativa is known for producing over 120 distinct phytocannabinoids, with Δ9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD) being the most prominent, primarily in their acidic forms. Beyond Δ9-THC and CBD, a wide array of lesser-known phytocannabinoids, along with terpenes, flavonoids, and alkaloids, demonstrate diverse pharmacological activities, interacting with the endocannabinoid system (eCB) and other biological pathways. These compounds, characterized by phenolic structures and hydroxyl groups, possess lipophilic properties, allowing them to cross the blood-brain barrier (BBB) effectively. Notably, their antioxidant, anti-inflammatory, and neuro-modulatory effects position them as promising agents in treating neurodegenerative disorders. While research has extensively examined the neuropsychiatric and neuroprotective effects of Δ9-THC, other minor phytocannabinoids remain underexplored. Due to the well-established neuroprotective potential of CBD, there is growing interest in the therapeutic benefits of non-psychotropic minor phytocannabinoids (NMPs) in brain disorders. This review highlights the emerging research on these lesser-known compounds and their neuroprotective potential. It offers insights into their therapeutic applications across various major neurological conditions.

The Use of Compounds Derived from Cannabis sativa in the Treatment of Epilepsy, Painful Conditions, and Neuropsychiatric and Neurodegenerative Disorders

Neurological disorders present a wide range of symptoms and challenges in diagnosis and treatment. Cannabis sativa, with its diverse chemical composition, offers potential therapeutic benefits due to its anticonvulsive, analgesic, anti-inflammatory, and neuroprotective properties. Beyond cannabinoids, cannabis contains terpenes and polyphenols, which synergistically enhance its pharmacological effects. Various administration routes, including vaporization, oral ingestion, sublingual, and rectal, provide flexibility in treatment delivery. This review shows the therapeutic efficacy of cannabis in managing neurological disorders such as epilepsy, neurodegenerative diseases, neurodevelopmental disorders, psychiatric disorders, and painful pathologies. Drawing from surveys, patient studies, and clinical trials, it highlights the potential of cannabis in alleviating symptoms, slowing disease progression, and improving overall quality of life for patients. Understanding the diverse therapeutic mechanisms of cannabis can open up possibilities for using this plant for individual patient needs.

The Brain Medicine Fellowship: A Competency-Based Training Program to Treat Complex Brain Disorders

PROBLEM

Complex brain disorders involve symptoms in the domains of affect, behavior, and cognition. It is increasingly recognized that there is a need for a novel type of physician who can treat individuals with these conditions in an interdisciplinary fashion to best address their complexity. Few training programs have focused on the education of such practitioners.

APPROACH

The authors outline the development and practices of the Brain Medicine Fellowship, an innovative, competency-based fellowship program at the University of Toronto Temerty Faculty of Medicine that accepts trainees from multiple brain medicine-related specialty training programs to develop expertise in integrative assessment and treatment of complex brain disorders. The authors describe how brain medicine competencies were generated, the current assessment process, and the seminal clinical experience associated with the fellowship-the Brain Medicine Clinic-and explain how it exemplifies brain medicine in action.

OUTCOMES

The first fellow was registered from July 2019 to December 2020. As of December 2022, 3 fellows have entered the program, with 3 more anticipated to begin in July 2023. More than 26 supervisors are associated with the fellowship, who offer a diversity of experiences for fellows to choose from in developing their individualized learning plans. The Brain Medicine Fellowship not only fosters the development of a novel type of clinician (a brain medicine specialist) but also is innovative in its educational design as one of the first nonsurgical fellowships to implement competency-based medical education and has resulted in original clinical programming in the form of the Brain Medicine Clinic, which benefits patients and their caregivers.

NEXT STEPS

The development of the Brain Medicine Fellowship continues with competency refinement and translation into entrustable professional activities and constituent milestones. A comprehensive program evaluation will be completed by 2025.

Psychosocial Basis of Human Sufferings and Poverty in Patients with Neurological and Psychiatric Disorders

Neurological disorders and psychiatric ailments often lead to cognitive disabilities and low attainment of education, pivoting misconceptions, myths, and misbeliefs. Poverty and low educational attainment are intriguingly associated with poor awareness and perception of these diseases that add to the suffering. Poverty goes parallel with a low level of education and is intricately associated with neuropsychiatric ailments, which have the potential to spread transgenerationally. Robust education policies, proper government rules and regulations against the spread of disease-related myths and misconceptions, uplifting medical education in its true sense, voices against consanguinity, and programs to raise scientific perception about diseases can help to throw light at the end of this dark tunnel. In this article, the authors intend to 1) decipher the potential psychosocial basis of human suffering and poverty in patients with neurological and psychiatric disorders, and 2) discuss the apropos way-outs that would potentially mitigate suffering, and alleviate the economic burden and cognitive disabilities of families with neuropsychiatric diseases.

Time for Brain Medicine

Unprecedented knowledge of the brain is inevitably contributing to the convergence of neurology and psychiatry. However, clinical training continues to follow a divergent approach established in the 19th century. An etiological approach will continue to shift more psychiatric patients to the care of neurologists who are untrained in psychiatric management. At the same time, this new era of diagnostic biomarkers and neuroscience-based precision treatments requires skills not readily available to those trained in psychiatry. The challenges in training the next generation of doctors include establishing competence involving aspects of the whole brain, fostering the subspecialized expertise needed to remain current, and developing programs that are feasible in duration and practical in implementation. A new 4-year residency training program proposed in this article could replace existing residency programs. The program includes 2 years of common and urgent training in various aspects of neurology and psychiatry followed by 2 years of elective subspecialty tracks. The concept is similar to internal medicine residencies and fellowships. No changes to existing departmental structures are necessary. In concert with the emerging biological approach to the brain, "brain medicine" is proposed as a new name to denote this practice in the simplest terms: a focus on all aspects of the brain.

Medical Student Attitudes and Perceptions on the Relevance of Neuroscience to Psychiatry: a Mixed Methods Study

OBJECTIVE

Many psychiatry residency programs are actively incorporating neuroscience training into their curricula; however, relatively little scholarship exploring neuroscience and psychiatry integration in undergraduate medical education has been conducted. This study investigated second-year, pre-clerkship medical students' perceptions on the relationship between neuroscience and psychiatry following foundational neuroscience and behavior instruction to identify their views before they enter clerkships.

METHODS

A mixed methods design combined qualitative analysis of medical students' essays in response to the prompt: "What is the relationship between neuroscience and psychiatry?" with quantitative analysis of survey responses on a 7-point scale.

RESULTS

Ninety-three percent of the class participated in the study (n = 77). Learners rated neuroscience as important for understanding and treating psychiatric disorders, albeit less important for psychiatric compared to neurological disorders. Using applied thematic analysis, the authors identified qualitative themes. Specifically, participants recognized neuroscience as a foundational science for psychiatry, but some emphasized that factors other than neuroscience are needed to explain psychiatric disorders. Some students perceived neuroscience and psychiatry as complementary approaches to understanding the brain and behavior. Others identified a role for neuroscience in reducing the stigma of psychiatric disorders and thereby improving access to psychiatric care.

CONCLUSIONS

The quantitative and qualitative findings reinforced each other and provided novel insight to pre-clerkship medical students' views on the relevance of neuroscience for psychiatry. Educating all medical students, not just psychiatry residents, on the neuroscience of psychiatric disorders may better equip the next generation of physicians, regardless of specialty, to care for their patients with psychiatric conditions.

Education Research: A Qualitative Study on Student Perceptions of Neurology and Psychiatry Clerkship Integration

OBJECTIVE

To explore student perceptions of the feasibility of neurology and psychiatry clerkship integration, including clinical education and competency evaluation, as there has been a call to improve undergraduate medical education integration of the disciplines to better develop physicians that can address nervous system disorders.

METHOD

Via a constructivist grounded theory approach, we carried out 5 focus groups in 2016-2017 with 28 medical students who completed both independent clerkships. Investigator triangulation was used with iterative interpretation comparisons, and themes were identified using constant comparative analysis.

RESULTS

Three major themes arose: (1) combining the clerkships was not favorable as students need sufficient time to delve deeper into each discipline; (2) students did not observe an integrated clinical approach by faculty; (3) there is positive value to making links between neurology and psychiatry for effective patient care.

CONCLUSIONS

Students emphasized the importance of making stronger links between the 2 disciplines for their learning and to improve patient care; however, they did not observe this clinical approach in the workplace. Students perceived that integration of neurology and psychiatry clerkships should occur via increased affinity of the complementary discipline by trainees and faculty in each specialty.

Primary Care and Neurology in Psychiatry Residency Training: a Survey of Early Career Psychiatrists

OBJECTIVE

A survey of recently certified psychiatrists was conducted to obtain their feedback about the contribution of the primary care and neurology components of residency training to their professional development and to their current needs as practitioners.

METHODS

A 22-item survey was developed based on issues discussed at a forum on residency competence requirements and administered electronically to four cohorts of recently certified psychiatrists.

RESULTS

The response rate was 17% (1049/6083). Overall, the respondents described both their primary care and neurology experiences as helping them accomplish several goals for their professional development. The majority were satisfied with their primary care training and felt well-prepared to enter practice. The most common suggestions for improving the primary care component were better integration with psychiatry and providing longitudinal experiences and more outpatient experience. They were somewhat less satisfied with their neurology training, and only about half felt well-prepared for the neurologic aspects of psychiatry practice. The most common suggestions for improving neurology training were to provide more time in neurology with experiences that were more relevant to psychiatry such as outpatient and consultation experiences. Some also thought longitudinal experiences would be useful.

CONCLUSIONS

These psychiatrists were generally satisfied with the primary care and neurology components of residency training and felt that they had contributed to their professional development. Their suggestions for improvement contribute to the rich discussion among training directors and other psychiatry educators about these components of residency training.

Psychiatric manifestations of neurologic diseases: Etiology, phenomenology, and treatment

Understanding the etiology and meaning of behavioral symptomatology in the context of neurologic disease, and choosing the most effective intervention is a vexing task. This introduction summarizes the history of our understanding of the relationship between behavioral symptoms and primary neurologic conditions, and considers the ways in which both psychiatric and neurologic disorders occurring simultaneously may inform both knowledge of etiology and treatment decisions.

Neuropsychiatry and neural cubism

The art movement known as Cubism did not represent a failure of perspective but, rather, was a movement aimed at advancing art by juxtaposing different perspectives. In this issue, Taylor and colleagues describe the current approach by neurologists and psychiatrists to patients with brain disorders as "Neural Cubism" because of the competing angles of these specialists' perspectives about these disorders. They advocate both integrated training for all residents in the two fields and a system of "nested hierarchies" to reclassify brain disorders according to their effect on levels of brain function. The unspoken premise of their article is that it is time for psychiatry and neurology to reunite.This Commentary takes the view that reuniting the long-separated specialties of neurology and psychiatry would not necessarily create better care for all patients with brain disorders but that trainees in both fields would benefit from increased training in the complementary specialty. The new Accreditation Council for Graduate Medical Education clinical neuroscience milestones for psychiatry training and psychiatry milestones for neurology training are steps in the right direction. Increasing opportunities for combined neurology-psychiatry training will help create a cadre of specialists equipped to efficiently care for complex patients within emerging accountable care organizations. Drawing from two fields in the service of understanding brain-behavior interactions increases the potential for innovation at their interface. The author concludes that the time has come to increase the neurological and neuroscience content of psychiatry training but not to unite the two fields.